Basic Information
| Provider Information | |||||||||
| NPI: | 1700593811 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AYELE | ||||||||
| FirstName: | TEDBABEWORK | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2168 QUAIL CREEK PKWY NE | ||||||||
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| City: | BLAINE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554493901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122962757 | ||||||||
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| Practice Location | |||||||||
| Address1: | 324 E 35TH ST | ||||||||
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| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554084580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128277181 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2022 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 9622 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.